Metropolitan Life Insurance Company Dear Employer and Employee/Member: the attached forms should be completed when applying for continuation of life insurance under any of the following provisions: Continued Protection (Premium Waiver During Total Disability) Continued Insurance During Total Disability Total & Permanent Disability Instructions for Completing Group Life Insurance Statement of Review Employer/Association s Statement 1. The Employer/Association s Statement should be completed by someone who is familiar with the employee/member s potential eligibility for Premium Waiver, Continued Insurance or Total Permanent Disability. 2. Complete Sections 1, 2, & 3 of the Employer/Association s Statement and sign at the bottom of the page. te: Failure to complete all sections or sign the Employer/Association s Statement will cause a delay in processing. 3. Give the completed Employer/Association s Statement and all remaining pages including this page to the employee/member. You may wish to retain a copy for your records. 4. Contact MetLife with any questions you may have when completing this form. Important: If MetLife does not maintain your Group Life records, please attach all enrollment forms, beneficiary designations, Job Descriptions, and any other forms in the claimant s life insurance records. Employee/Member s Statement 1. The Employee/Member s Statement must be completed by the employee/member or authorized representative. If you are an authorized representative completing this form, please include a copy of the legal document(s) authorizing you to act on the Employee/Member s behalf. 2. Complete the Employee/Member s Statement. 3. Sign the following pages: a) the Employee/Member s Statement b) the Authorization to Disclose Information About Me c) the Attending Physician Statement, Section A 4. Give the Attending Physician Statement to your treating physician for completion. 5. Contact MetLife with any questions you may have when completing this form. 6. Submit all forms, including the Attending Physician Statement completed by your physician, to MetLife at the above address. Page 1 of 7 G.CP-CI-TP (02/14)
GROUP LIFE INSURANCE STATEMENT OF REVIEW Please check all appropriate boxes for this submission Continued Protection (Premium Waiver During Total Disability) Continued Insurance During Total Disability Total & Permanent Disability EMPLOYER/ASSOCIATION S STATEMENT Section 1: Employer/Association Information Metropolitan Life Insurance Company Important: If MetLife does not maintain your Group Life records, please attach all enrollment forms, beneficiary designations, and any other forms in the claimant s life insurance records. Employer/Association Name Name of Group Policyholder if different than the Employer/Association Address of Employer/Association or Group Policyholder City State Zip Code Address of Group Policyholder if different than the Employer/Association City State Zip Code Contact Person s Name Phone # Fax # E-mail Address Section 2: Employee/Member Information Name (Last, First, MI) Social Security # - REQUIRED Date of Birth (MM/DD/YY) Address City State Zip Code Claimant s Occupation/Job Title (Attach a job description) Date of Hire Salaried Hourly Base Wages as of Last Date Worked Hourly Weekly Monthly Section 3: Coverage Information (complete all fields for each applicable coverage) Date Last Worked? Has employee/member had previous absences from work due to disability? Coverage Basic Life Dependent Life Supplemental/ Optional Life Amount of Insurance as of Date Last Worked Accidental Death & Dismemberment (AD&D) Supplemental/ Optional Life & Accidental Death & Dismemberment GUL Report Number Does your company provide retirement benefits? If, see Sub Code Number Branch Number Employer/Association s Authorized Representative Why did employee/member cease work on that date? If yes, provide dates and medical conditions. Employee/Member Life Insurance Effective Date Under Employer/Association's Plan Check type of benefit: rmal Disability Date Insurance Amount Last Changed Would the Employee/Member Qualify? Name (Please Print) Title Phone # Signature Cancellation Date (if any) Number of hours worked per week: Premium Payments Terminated? Was group coverage converted to an individual policy? Date on which Employee/Member would qualify? Page 2 of 7 G.CP-CI-TP (02/14)
FRAUD WARNINGS Before signing this claim form, please read the warning for the state where you reside and for the state where the insurance policy under which you are claiming a benefit was issued. Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Delaware, Idaho, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Florida: A person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in R.S.A. 638.20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Oregon and Vermont: Any person who knowingly presents a false statement of claim for insurance may be guilty of a criminal offense and subject to penalties under state law. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars (5,000), not to exceed ten thousand dollars (10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Page 3 of 7 G.CP-CI-TP (02/14)
GROUP LIFE INSURANCE STATEMENT OF REVIEW Contact MetLife with any questions you may have when completing this form. Submit the entire form by mail to the above address for processing. Retain a copy for your records. Important: To avoid processing delays, please complete the form in its entirety and submit all requested documents. EMPLOYEE/MEMBER S STATEMENT Section 1: Personal Information Metropolitan Life Insurance Company Name (Last, First, MI) Social Security # - REQUIRED E-Mail Address (Optional) Address City State Zip Code Date of Birth (MM/DD/YY) Male Female Home Phone # Occupation Marital Status Married Single Other Education (Select highest level completed) GED High School Associate Degree Bachelors Degree Vocational/Other Masters Degree or higher Dependent Information for Group Life Insurance: Name Date of Birth SS# Spouse Children Section 2: Disability Information Date Last Worked State the cause of your Disability: On what date were you first treated by a physician related to this disability? Name(s) of all Physicians/Providers who have treated you since the beginning of this disability: Phone Number Name of Physician/Provider Address Dates of Treatment Reason for Visit (Include Area Code) Have you performed any type of work (either for this employer/association, another employer/association or through self-employment) since your disability began? If, provide the following information: Name of Employer/Association Address of Employer/Association Type of Work Date Employment Began Hours Worked Per Week Are you presently able to engage in any gainful occupation? If, please explain: If, when do you expect to return to work? Date Are you insured under any other policies issued by MetLife? If, please provide coverage type and policy numbers: Certifications and Signature: By signing below, I acknowledge: 1. All information I have given is true and complete to the best of my knowledge and belief. 2. I have read the applicable Fraud Warning(s) provided in this form. New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Employee/Member Signature Page 4 of 7 G.CP-CI-TP (02/14)
Metropolitan Life Insurance Company This Authorization has been carefully and specifically drafted to permit disclosure of health information consistent with the privacy rules adopted and subsequently amended by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Your refusal to complete and sign this form may affect your eligibility for benefits under your employer/association s life plan. Name of Claimant (Please Print) Social Security Number Authorization to Disclose Information About Me For purposes of determining my eligibility for continued life insurance coverage due to a disability or for the total and permanent disability benefit under the administration of my employer/association s life benefit plan, as the case may be, I permit the following disclosures of information about me to be made in the format requested, including by telephone, fax or mail: 1. I permit: any physician or other medical/treating practitioner, hospital, clinic, other medical related facility or service, nsurer, employer/association, government agency, group policyholder, contractholder or benefit plan administrator to disclose to Metropolitan Life Insurance Company ( MetLife ), my employer/association in its capacity as administrator of its life benefit plan, and any consumer reporting agencies, investigative agencies, attorneys, and independent claim administrators acting on MetLife s behalf, any and all information about my health, medical care, employment, and disability claim. 2. I permit MetLife to disclose to my employer/association in its capacity as administrator of its benefit plans any and all information about my health, medical care, employment, and disability claim. This Authorization to Disclose Information About Me specifically includes my permission to disclose my entire medical record, including medical information, records, test results, and data on: medical care or surgery; psychiatric or psychological medical records, but not psychotherapy notes; and alcohol or drug abuse including any data protected by Federal Regulations 42 CFR Part 2 or other applicable laws. Information concerning mental illness, HIV, AIDS, HIV related illnesses and sexually transmitted diseases or other serious communicable illnesses may be controlled by various laws and regulations. I consent to disclosure of such information, but only in accordance with laws and regulations as they apply to me. Information that may have been subject to privacy rules of the U.S. Department of Health and Human Services, once disclosed, may be subject to redisclosure by the recipient as permitted or required by law and may no longer be covered by those rules. Your health care provider may not condition your treatment on whether you sign this authorization. I understand that I may revoke this authorization at any time by writing to MetLife at, Lexington, KY 40512-4632, except to the extent that action has been taken in reliance on it. If I do not, it will be valid for 24 months from the date I sign this form or the duration of my claim for benefits, whichever period is shorter. A photocopy of this authorization is as valid as the original form and I have a right to receive a copy upon request. Signature of Claimant or Authorized Representative Page 5 of 7 G.CP-CI-TP (02/14)
ATTENDING PHYSICIAN STATEMENT EMPLOYEE/MEMBER: 1. Complete Section A and the Name/SSN section on the next page. 2. Sign Section A and provide this form to your physician. 3. After your physician completes the form, fax or mail all forms and records to MetLife. Retain originals for your records. ATTENDING PHYSICIAN: Objective Findings to be included: Diagnostic Testing results (x-rays; lab tests; EKGs; MRIs and scans). Office Visit tes (from patient s date last worked to present). Admission or Discharge Summaries for recent hospitalizations/surgeries. Section A Name Social Security # Required Date of Birth Employer/Association Occupation Group Report # Metropolitan Life Insurance Company I hereby authorize my physician to release any information acquired in the course of my examination or treatment. Signature of Employee/Member Section B The purpose of this report is to assist us in making a disability determination. Please complete all applicable sections of this form. A MetLife claim representative may telephone your office if additional information is needed. History Symptoms result from: Injury Illness Is condition work-related? Initial date of treatment Most recent date of treatment Did you advise the patient to cease the above noted occupation? If, Date Names and Phone Numbers of the other providers the patient was referred to: Name Phone # Name Phone # Has patient been hospitalized? Name and address of facility: If, Date Confined through Diagnosis and Treatment Primary ICD-9. Diagnosis Secondary ICD-9. Diagnosis Subjective Symptoms Objective Findings (Include copies/results of any x-rays, lab tests, EKG s, MRI s, scans and office notes) Current and Recommended Treatment Plans If surgery performed/anticipated, provide the following: CPT-4 Procedure Date Medications prescribed (names, dosages) Page 6 of 7 G.CP-CI-TP (02/14)
Name of Employee/Member Psychological Functions Check applicable box below Social Security Number Class 1 Patient is able to function under stress and engage in interpersonal relations (no limitations) Class 2 Patient is able to function in most stress situations and engage in some interpersonal relations (slight limitations) Class 3 Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations) Class 4 Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations) Class 5 Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) Remarks: What stress factors or problems with interpersonal skills have affected patient s ability to perform the duties of his or her job? Is patient competent to endorse checks and direct use of the proceeds? Physical Capabilities (a) Patient s ability to: (circle) Hours (check) Sit 0 1 2 3 4 5 6 7 8 Continuously Intermittently Stand 0 1 2 3 4 5 6 7 8 Continuously Intermittently Walk 0 1 2 3 4 5 6 7 8 Continuously Intermittently (c) Patient s ability to lift/carry: (check) Never Occasionally Frequently Continuously 0% 1-35% 36-66% 67%-100% Up to 10 lbs. 11 to 20 lbs. 21 to 50 lbs. 51 to 100 lbs. Over 100 lbs. (e) In your opinion, why is patient unable to perform job duties? (f) Patient can work a total of hours per day? (g) Do you expect improvement in any area? (If so please comment and give dates/timeframes.) (b) Patient s ability to: (circle) Climb Twist/bend/stoop Reach above shoulder level Operate a motor vehicle (d) Patient s ability to perform repetitively: (circle) Right Hand Left Hand Fine finger movements Eye/hand movements Pushing/pulling Dominant hand Right Hand Left Hand (h) Has patient reached maximum medical improvement? If YES, is the condition permanent? Cardiac: Functional Capacity (American Heart Association) Complete only if applicable. Class 1 ( Limitation) Class 2 (Slight Limitation) Class 3 (Marked Limitation) Class 4 (Complete Limitation) Blood pressure (latest reading) / as of (date) / Is patient in a cardiac rehabilitation program? Extent of Disability For Any Occupation For His/Her Regular Occupation (a) Is Patient now totally disabled? (b) If no, when was patient able to go to work? Mo. Day Yr. Mo. Day Yr. (c) If yes, when do you think patient will be able to resume any work? Approximate Date: Mo. Day Yr. Mo. Day Yr. Indefinite: Never: Rehab Do you suggest that the patient become involved in any of the following? Please check as many as apply. If so, was this discussed with the patient? Physical Therapy Occupational Therapy Cardiac Rehabilitation Pain Management Program Work Hardening Program Job Modification Vocational Rehabilitation Psychological Counseling Other Physician Print Name Degree/Specialty Street Address City State Zip Code Telephone # Fax # Tax ID # Contact person if additional information is necessary Signature Please be sure to submit the objective findings outlined on the first page of this Attending Physician Statement (include copies/results of any x-rays, lab tests, EKGs, MRIs, scans and office notes). Page 7 of 7 G.CP-CI-TP (02/14)